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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800192
Report Date: 03/13/2023
Date Signed: 03/13/2023 01:57:17 PM

Document Has Been Signed on 03/13/2023 01:57 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MEMBERS MVPFACILITY NUMBER:
331800192
ADMINISTRATOR:NIKKI VON JENAFACILITY TYPE:
735
ADDRESS:31588 VINTNERS POINTE CTTELEPHONE:
(951) 325-5506
CITY:WINCHESTERSTATE: CAZIP CODE:
92596
CAPACITY: 4CENSUS: 4DATE:
03/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Nikki Von Jenna, AdministratorTIME COMPLETED:
02:00 PM
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Licensing Program Analyst, Amber Coleman (LPA) arrived at the Member's MVP Adult Facility to conduct an Annual Inspection. LPA was greeted by Administrator, Nikki Von Jena at the door. LPA introduced self and stated purpose of the visit. LPA was granted entry and asked to sanitize and sign in. LPA was informed the current census is 4, but all residents were attending their prospective Day Programs at time of visit.
LPA's visit consisted of a walk through of the facility, staff interview and review of files.

Personnel Records/Training/and Staffing- LPA reviewed employee record for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification, and current administrator certification. Records observed to be complete and adequate.

Resident Records/Incident Reports/Personal Rights/Residents with Special Needs/Incidental Medial and Dental- LPA began review of resident records. Four (4) records were reviewed. LPA reviewed for admission agreement, medical assessments and TB test results, consent forms, identification and emergency information documents, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification.

Resident rooms - all included required furniture, observed in good repair. Rooms clean and orderly. Adequate storage space and access to clean linens and hygiene products. Bathrooms observed to included appropriate hand soap, and paper towels.

Food Service- Staff observed preparing a meal for residents upon their arrival home. LPA observed a secure drawer for sharp objects. LPA also observed secure cabinets for cleaning solutions. Food prep areas are cleanly and orderly. Food supply meets the requirements of regulations- (1) week supply of nonperishable and two (2) day supply of perishables food on hand. Emergency rations were observed in the garage along with emergency supplies for facility.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MEMBERS MVP
FACILITY NUMBER: 331800192
VISIT DATE: 03/13/2023
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The facility conducts monthly fire/earthquake drills. Last fire drill 1/18/23 and last earthquake drill 1/18/23. Fire extinguisher last inspected July 2022. 2 COVID stations equipped with PPE, and infection control materials accessible to visitors and those who need them.

CARE Tool utilized. No deficiencies observed during today's visit. An exit interview was conducted were this report was discussed and provided to facility Administrator, Nikki Von Jenna.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023
LIC809 (FAS) - (06/04)
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